Failure to Ensure Safe Medication Administration and Storage
Penalty
Summary
The facility failed to ensure the safe disposition and administration of medications for a resident, as evidenced by the presence of an Albuterol Sulfate Inhaler left unattended at the bedside of a resident with chronic obstructive pulmonary disease (COPD), cognitive communication deficit, lack of coordination, weakness, and a disorder of the brain. The resident was assessed as cognitively intact but required varying levels of assistance with daily activities, including substantial or maximal assistance with toileting, bathing, and dressing. Despite these needs, there was no documented assessment for the resident's ability to self-administer medications, nor was there a physician's order permitting self-administration or allowing the inhaler to be kept at bedside. Review of the facility's policy indicated that residents must be assessed for self-administration of medication upon admission, quarterly, annually, with significant changes, or as needed. The policy also required an interdisciplinary team review, a physician's order, and care plan updates if self-administration was approved. In this case, the resident's clinical record, care plan, and medication administration record (MAR) showed no evidence of such an assessment, order, or care plan update. The MAR also lacked documentation of the inhaler being administered during the review period, despite the resident's need for frequent use of the inhaler for shortness of breath. Interviews with facility staff, including an LPN, the Director of Nursing, and the Administrator, confirmed that the resident had not been assessed for self-administration, did not have a physician's order for self-administration or for the inhaler to be kept at bedside, and that the medication should have been secured in the medication cart when not in use. Staff also confirmed that, even if self-administration were permitted, the date and time of administration should be documented on the MAR, which was not done in this case.